Information Collection

Patient #2 Survey Completes

IC 216612 under ICR 201505-0910-003 · OMB 0910-0801.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix 3. Optum Patient Pill Appearance Survey.docx	Other-Optum Patient Pill Appearance
Appendix 10. Optum Patient Survey Informed Consent Statement.docx	Other-Optum Patient Survey Informed
Appendix 9. Optum Patient Survey Initial Invitation Letter.doc	Other-Optum Patient Survey Initial I
Appendix 11. Optum Patient Survey Second Invitation Letter.doc	Other-Optum Patient Survey Second In

IC Title:

Agency IC Tracking Number:

CDER

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Optum Patient Pill Appearance Survey	Appendix 3. Optum Patient Pill Appearance Survey.docx	Yes	Yes	Fillable Fileable Signable
Other-Optum Patient Survey Informed Consent Statement	Appendix 10. Optum Patient Survey Informed Consent Statement.docx	Yes	Yes	Fillable Fileable Signable
Other-Optum Patient Survey Initial Invitation	Appendix 9. Optum Patient Survey Initial Invitation Letter.doc	Yes	Yes	Fillable Fileable Signable
Other-Optum Patient Survey Second Invitation	Appendix 11. Optum Patient Survey Second Invitation Letter.doc	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 20 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	300	300
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.